CHAPTER 9 PERFORMANCE IMPROVEMENT HOSPITAL

1 CHAPTER 9 PERFORMANCE IMPROVEMENT HOSPITAL PERFORMANCE IMPROVEMENT Introduction to terminology and requirements PERFORMANCE IMPROVEMENT (PI) PI program required by: o Florida Board of Pharmacy o The Joint Commission o Center for Medicaid/Medicare Services (CMS) Powerful tool Systematic process o Example: Plan Do Study Act (PDSA) methodology Focus on patient safety and optimizing care Required areas for HOSPITAL PERFORMANCE IMPROVEMENT : Medication Error Detection and Prevention Program Adverse Drug Reactions CMS HOSPITAL Core Measures Medication Use Evaluation (MUE) Proactive Risk Assessment (FMEA) External Benchmarking optional Medication Error Detection and Prevention Program Florida Board of Pharmacy Requirement for Continuous Quality IMPROVEMENT Program (CQI) to identify quality related events and to improve patient care (64B16 ).

2 Applies to all pharmacy permits Inappropriate dispensing o Variation from the prescription (incorrect drug strength, dosage form, patient, inadequate or incorrect labeling or directions) o Failure to identify and manage therapy (under or over utilization, duplication, contraindications, interactions, duration, allergy, or monitoring) Requires policy and procedure Quarterly meetings with documentation requirements for 4 years Includes assessing the impact of staffing levels, work flow, and technical support Medicare CoP (b) (6) and The HOSPITAL must report drug administrative errors, adverse drug reactions and drug incompatibilities to its HOSPITAL wide QAPI program . Definition of medication error and ADR should be broad enough to include near misses.

3 Program should be non punitive with the focus on the system and not the involved health care professionals. The Joint Commission ( ) The HOSPITAL collects data on significant medication errors and significant adverse drug reactions, adverse events related to moderate or deep sedation or anesthesia, and the use of blood and blood components. Root cause analysis (RCA) required for sentinel events. o Definition: Unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury includes loss of limb or function. o Voluntary reporting to The Joint Commission. Includes assessment of human factors, equipment factors, controllable environmental factors and uncontrollable external factors, leadership issues such as culture and communication.

4 O Commonly identified root causes include medication use (formulary, storage/control, labeling, ordering, preparing/distributing, administering and/or patient monitoring) with most having multiple root causes (leadership, communication, human factors, assessment, information management, physical environment, continuum of care, care planning, and patient education) CODE 15 state required reporting of significant medical errors. Reported by HOSPITAL Risk Manager. Pharmacy Director involved if medication event. Adverse Drug Reactions TJC Standard The HOSPITAL responds to actual or potential adverse drug events, significant adverse drug reactions, and medication errors. The HOSPITAL has a written process addressing prescriber notification in the event of an adverse drug event, significant adverse drug reaction, or medication error.

5 HOSPITAL Core Measures The Joint Commission ORYX Core Measures are required to be reported by hospitals measurement results posted for public on HOSPITAL Compare website ( ) Compliance affects HOSPITAL reimbursement Acute Myocardial Infarction (AMI) Aspirin at Arrival Aspirin at Discharge ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction Beta Blocker at Arrival Beta Blocker at Discharge Fibrinolytic Medication Within 30 Minutes Of Arrival Percutaneous Coronary Intervention (PCI) Received Within 90 Minutes of HOSPITAL Arrival Smoking Cessation Advice/Counseling Heart Failure Evaluation of Left Ventricular Systolic (LVS) Function ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction Discharge Instructions Smoking Cessation Advice/Counseling Pneumonia Oxygenation Assessment Pneumococcal Vaccination Influenza Vaccination Blood Culture Performed in the Emergency Department Prior to Initial Antibiotic Received in HOSPITAL Appropriate Initial Antibiotic Selection Smoking Cessation Advice/Counseling Surgical Care IMPROVEMENT /Surgical Infection Prevention (SCIP)

6 Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time Prophylactic Antibiotic Selection Appropriate Venous Thromboembolism Prophylaxis started at the right time Appropriate body temperature Perinatal Care Venous Thromboembolism (VTE) Stroke (STK) HOSPITAL Based Inpatient Psychiatric Services (HBIPS) Children's Asthma Care Mortality Readmission rates External Benchmarking 2014 Quality and Accountability PERFORMANCE ScorecardIncludes PSI metrics: PSI-03 pressure ulcer, PSI-06 iatrogenic pneumothorax, PSI-09 postoperative hemorrhage or hematoma, PSI-11 postoperative respiratory failure, NHSN metrics: Central Line Associated Blood Stream Infection, Catheter Associ ated Urinary Tract Infection, Surgical Site Infection, and Core Measure: VTE-06 venous *88*The goal of the Quality and Accountability ranking is to assess organizational PERFORMANCE across a broad spectrum of high-priority dimensions of patient care.

7 The 2014 scoring and ranking cover the domains of mortality, effectiveness, safety, equity, patient centeredness and efficiency using measures developed by national organizations or the federal government. Refer to the methodology white paper (available at ) for specifics regarding the metrics, scoring methods, and data sources O/E and direct cost O/E for following selected service lines: cardiology, gastroenterology, medical oncology, general medicine, neurology, general surgery, neurosurgery, CT surgery (cardiac surgery and thoracic surgery combined). Cases within the above service lines with 1 day LOS and an MS-DRG in the following list are excluded: 069, 190, 191, 192, 291, 292, 293, 313, 391, 392, 223, 225, 226, 227, 242, 243, 244, 245, 246, 248, 249, 251, 259, 261 and 10 HCAHPS questions on nurse communication, doctor communication, pain management, communication about medications, cleanliness and quietness, responsiveness of staff, discharge information and overall rating of the HOSPITAL averaged as a Health Shands HospitalOverallRatingCompositeScoreTop-P erformer ScoreGroup (* denotes tie)Domain ScoreTop-Performer ScoreGroup MedianOverall Composite PerformanceClinical Domain PerformanceMortality (25%)46* UHC O/E mortality rate for the following selected product service lines.

8 Bone marrow transplant, burns, cardiology, cardiothoracic surgery, cardiac surgery, thoracic surgery, gastroenterology, gynecology, gynecologic oncology, heart/lung transplant, HIV, kidney/pancreas transplant, liver transplant, medical oncology, medicine general, neurology, neurosurgery, obstetrics, orthopedics, otola ryngology, plastic surgery, rheumatology, spinal surgery, surgical oncology, surgery general, trauma, urology, and vascular all-cause readmission rate within 30 days after discharge and Joint Commission HOSPITAL Core Measures composite scores for AMI, HF, PN, and SCIP (IP and OP), STK, VTE: percentage of patients who received the care they were eligible to receive; as well as PERFORMANCE on the ED-1b, ED-OP-18b (median time) and IMM-1a and IMM-2 Joint Commission HOSPITAL Core Measures composite scores for AMI, HF, PN, SCIP-IP, ED-1b, IMM-1a, IMM-2, STK and VTE, testing for statistically significant differences in outcomes in 3 equity-based dimensions: gender (male vs.)

9 Female), race (white vs. nonwhite), and socioeconomic status (Medicaid, self-pay, uninsured, and charity combined vs. all others).(Based on Clinical Domain PERFORMANCE )Effectiveness (25%) (5%) (10%) document presents the measures evaluated in the 2014 UHC Quality and Accountability ranking. This scorecard provides a comparison of your organization's PERFORMANCE with that of other academic medical centers. The data were obtained from existing UHC data resources, including the Clinical Data Base (Q3 2013 Q2 2014), Core Measures Data Base (Q2 2013 Q1 2014), as well as HCAHPS data from the HOSPITAL Compare Web site (Q4 2012 Q3 2013) and National Healthcare Safety Network data (Q2 2013 Q1 2014).Patient Centeredness (10%) * (25%) 2014 University HealthSystem Consortium.

10 All rights reserved. NOTICE: This document contains proprietary information that is confidential and protected by state and federal privacy and peer review laws. Any unauthorized copying of this document is forbidden Medication Use Evaluation (MUE) The Joint Commission specifies data may be collected retrospectively or prospectively Focus on specific drug or treatment Target drug, drug class, or disease MUE based on high risk, high volume, problem prone, new formulary item, or request from health care practitioner 1. Prescribing examples: a. Appropriate use of vancomycin with goal to reduce resistance and drug related morbidity b. Appropriate dosage of drugs i. Adjustment for renal function ii. Adjustment for patient weight c.